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Introduction: The postural instability gait difficulty motor subtype of patients with Parkinson's disease (PIGD-PD) has been associated with more severe cognitive pathology and a higher risk on dementia compared to the tremor-dominant subtype (TD-PD). Here, we investigated whether the microstructural integrity of the cholinergic projections from the nucleus basalis of Meynert (NBM) was different between these clinical subtypes., Methods: Diffusion-weighted imaging data of 98 newly-diagnosed unmedicated PD patients (44 TD-PD and 54 PIGD-PD subjects) and 10 healthy controls, were analysed using diffusion tensor imaging, focusing on the white matter tracts associated with cholinergic projections from the NBM (NBM-WM) as the tract-of-interest. Quantitative tract-based and voxel-based analyses were performed using FA and MD as the estimates of white matter integrity., Results: Voxel-based analyses indicated significantly lower FA in the frontal part of the medial and lateral NBM-WM tract of both hemispheres of PIGD-PD compared to TD-PD. Relative to healthy control, several clusters with significantly lower FA were observed in the frontolateral NBM-WM tract of both disease groups. Furthermore, significant correlations between the severity of the axial and gait impairment and NBM-WM FA and MD were found, which were partially mediated by NBM-WM state on subjects' attentional performance., Conclusions: The PIGD-PD subtype shows a loss of microstructural integrity of the NBM-WM tract, which suggests that a loss of cholinergic projections in this PD subtype already presents in de novo PD patients., (Copyright © 2021 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Although impaired postural control may be a risk factor for distal radius fractures (wrist fractures), which often are caused by falls, little attention has been given thus far to the various performance and neurophysiologic aspects involved. Although studies suggest that external focus and cognitive tasks can improve postural control, it remains unclear whether these benefits are observed in individuals with a history of distal radius fracture and to what extent., Questions/purposes: (1) To compare patients with a history of distal radius fracture to age- and sex-matched controls in terms of postural stability while standing on stable and unstable support surfaces, using both postural sway and neurophysiological measures as endpoints; and (2) to determine whether internal- and external-focus strategies and cognitive tasks can improve postural stability in these patients., Methods: Forty patients with distal radius fracture (33 females and seven males with a mean ± SD age of 56 ± 4 years) and 40 sex- and age-matched control participants participated in the study. We recruited patients with a history of fall-induced distal radius fractures occurring between 6 and 24 months before the start of our study. We excluded patients who had any of the following: fear of falling, taking any medication that may affect balance, neurologic disorders, dizziness, vestibular problems, Type II diabetes, musculoskeletal disorders or recent history of lower extremity fracture, any recent surgical interventions in the spine or lower limbs, and/or cognitive impairment. Of 120 patients who were being treated for distal radius fracture over the 18-month period, 91 (76%) agreed to participate and 40 eligible patients were finally enrolled. The control group included sex- and age-matched (within 2-year intervals) individuals who had never had a wrist fracture. This group was selected from attendants/relatives of the patients attending the neurology and physical medicine and rehabilitation outpatient departments, as well as other volunteers with no history of balance problems or wrist fractures. To address our primary research question, we compared the postural control of individuals with a history of distal radius fracture with the control group while quietly standing on different support surfaces (rigid and foam surfaces) using both postural sway measures obtained by a force plate as well as neurophysiological measures (electromyography [EMG] activity of tibialis anterior and medial gastrocnemius). To address our secondary research question, we compared the postural sway measures and EMG activity of the ankle muscles between different experimental conditions (baseline, internal focus (mentally focusing on their feet without looking), external focus (mentally focusing on rectangular papers, placed on the force plate or foam, one under each foot), difficult cognitive task (recalling maximum backward digits plus one) and easy cognitive task (recalling half of the maximum backward digits)., Results: Patients with distal radius fractures presented with greater postural sway (postural instability) and enhanced ankle muscle activity compared with their control counterparts, but only while standing on a foam surface (mean velocity: 5.4 ± 0.8 versus 4.80 ± 0.5 [mean difference = 0.59, 95% CI of difference, 0.44-0.73; p < 0.001]; EMG root mean square of the tibialis anterior: 52.2 ± 9.4 versus 39.30 ± 6 [mean difference = 12.9, 95% CI of difference, 11.4-14.5; p < 0.001]). Furthermore, a decrease in postural sway was observed while standing on both rigid and foam surfaces during the external focus, easy cognitive, and difficult cognitive conditions compared with the baseline (for example, mean velocity in the baseline condition compared with external focus, easy cognitive task and difficult cognitive task was: 4.9 ± 1.1 vs 4.7 ± 1 [mean difference = 0.14, 95% CI of difference, 0.11-0.17; p < 0.001], 4.6 ± 1 [mean difference = 0.25, 95% CI of difference, 0.21-0.29; p < 0.001], and 4.5 ± 1 [mean difference = 0.34, 95% CI of difference, 0.29-0.40; p < 0.001] in the wrist fracture group). The same result was obtained for muscle activity while standing on foam (EMG root mean square of tibialis anterior in the baseline condition compared with external focus, easy cognitive task and difficult cognitive task: 58.8 ± 7.2 versus 52.3 ± 6.6 [mean difference = 6.5, 95% CI of difference, 5.5-7.6; p < 0.001], 48.8 ± 7.1 [mean difference = 10.1, 95% CI of difference, 9-11.1; p < 0.001], 42.2 ± 5.3 [mean difference = 16.7 95% CI of difference, 15.1-18.2; p < 0.001] in the wrist fracture group)., Conclusions: The current results suggest that patients with a history of distal radius fractures have postural instability while standing on unstable support surfaces. This instability, which is associated with enhanced ankle muscle activity, conceivably signifying an inefficient cautious mode of postural control, is alleviated by external attention demands and concurrent cognitive tasks., Clinical Relevance: The findings of this study may serve as a basis for designing informed patient-specific balance rehabilitation programs and strategies to improve stability and minimize falls in patients with distal radius fractures. The integrative methodology presented in this work can be extended to postural control and balance assessment for various orthopaedic/neurological conditions.

Objective: Fast and scaled muscular activation is required to recover body balance following an external perturbation. An issue open to investigation is the extent to which the cerebral hemisphere lesioned by stroke leads to asymmetric deficits in postural reactive responses. In this experiment, we aimed to compare muscular responses to unanticipated stance perturbations between individuals who suffered unilateral stroke either to the right or to the left cerebral hemisphere., Methods: Stance perturbations were produced by releasing a load attached to the participant's trunk, inducing fast forward body oscillation. Electromyography was recorded from the gastrocnemius medialis and biceps femoris muscles. Muscular activation from age-matched healthy individuals was taken as reference., Results: Analysis indicated that damage to the right hemisphere induced delayed activation onset, and lower rate and magnitude of activation of the proximal and distal muscles of the paretic leg. Those deficits were associated with stronger activation of the nonparetic leg. Comparisons between left hemisphere damage and controls showed deficits limited to activation of the biceps femoris of the paretic leg. Manipulation of visual information led to no significant effects on muscular responses., Conclusions: These results suggest that right cerebral hemisphere damage by stroke leads to more severe deficits in the generation of reactive muscular responses to stance perturbation than damage to the left cerebral hemisphere regardless of visual information., (Copyright © 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.)

Objective: Subjects with greater trochanteric pain syndrome (GTPS) show an altered physical function while performing static and dynamic tasks. Pain and psychosocial factors are also variables that influence the outcomes of these patients. Thus, the aim of this study was to evaluate the relationship between dynamic balance, pain-related measures, and psychosocial measures in subjects with chronic GTPS., Design: Descriptive cross-sectional study., Setting: Primary health care center., Subjects: Fifty-one subjects with greater trochanteric pain syndrome were recruited., Methods: Dynamic balance was evaluated using the Y-Balance Test (YBT), and a self-reported test battery was used to assess the following aspects: pain catastrophizing (Pain Catastrophizing Scale [PCS]), kinesiophobia (Tampa Scale of Kinesiophobia [TSK-11]), pain intensity (visual analog scale [VAS]), disability (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC]), and self-efficacy (Chronic Pain Self-Efficacy Scale [CPSS])., Results: Correlation analysis showed that YBT was negatively associated with the VAS average, the helplessness subscale of the PCS, and the pain and function subscales and total score of the WOMAC. YBT was positively associated with the pain subscale of the CPSS. The scores of the YBT forward movement were predicted by the VAS average (38.1% of variance) in addition to the WOMAC total score (34.2% of variance) and TSK-11 total score (43.8% of variance)., Conclusions: The findings of this study suggest that kinesiophobia, pain, and physical function are related to dynamic balance in subjects with GTPS. Thus, when diagnosing and planning the treatment of patients with GTPS, psychosocial and physical function factors should be taken into account, in addition to pain management., (© 2018 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Purpose: Military service members often report both affective and vestibular complaints after mild traumatic brain injury (mTBI), but associations between symptoms and vestibular deficits can be subtle and inconsistent., Methods: From two complementary studies, one of military service members with persistent post-concussive symptoms after mTBI (NCT01611194) and the other of adult volunteers with no history of brain injury (NCT01925963), affective symptoms were compared to postural control, gait, otolith and visuospatial function., Results: The studies enrolled 71 participants with mTBI and 75 normative controls. Participants with mTBI had significantly reduced postural equilibrium on the sensory organization test (SOT), and more so in those with high anxiety or post-traumatic stress. Cervical and ocular vestibular evoked myogenic potentials (cVEMP; oVEMP) showed prolonged latencies in mTBI participants compared to controls; oVEMPs were significantly delayed in mTBI participants with high anxiety, post-traumatic stress or depression. A subset of the mTBI group had abnormal tandem gait and high anxiety. Anxiety, post-traumatic stress, and depression did not correlate with performance on the 6-Minute Walk Test, visuospatial neuropsychological measures, and the Satisfaction with Life Scale in the mTBI group., Conclusion: In this study military service members with mTBI reported affective symptoms, concurrently with vestibular-balance concerns. Worse scores on affective measures were associated with abnormal findings on measures of postural control, gait and otolith function., Competing Interests: The authors of this paper declare no conflicts of interest exist with this submission., (Copyright© Undersea and Hyperbaric Medical Society.)

Objective: The aim of this study was to investigate the association of regional plantar tactile sensitivity with balance and mobility in community-dwelling older people., Methods: Fifty-five older adults (39 women and 16 men) mean age 73.5 ± 6.5 years participated in the study. Plantar tactile sensitivity was assessed at nine regions of the foot using Semmes-Weinstein monofilaments. Balance and mobility of the subjects were evaluated with Berg Balance Scale and Rivermead Mobility Index, respectively., Results: Plantar tactile sensitivity was not significantly correlated with balance and mobility scores. No significant differences were obtained when balance and mobility scores were compared between subjects with and without plantar sensitivity., Conclusions: This study revealed that plantar tactile sensory was not associated with balance and mobility functions in older adults. This result may be related to the protection of other sensory systems supporting the maintenance of balance and mobility functions in physically active community-dwelling older people., (© 2018 AJA Inc.)

Background: fear of falling is prevalent among older people and associated with various health outcomes. A growing number of studies have examined the effects of interventions designed to reduce the fear of falling and improve balance among older people, yet our current understanding is restricted to physiological interventions. Psychological interventions such as cognitive behavioural therapy (CBT) have not been reviewed and meta-analysed., Objective: to perform a systematic review and meta-analysis evaluating the effects of CBT on reducing fear of falling and enhancing balance in community-dwelling older people., Method: randomised controlled trials (RCTs) addressing fear of falling and balance were identified through searches of six electronic databases, concurrent registered clinical trials, forward citation and reference lists of three previous systematic reviews., Results: a total of six trials involving 1,626 participants were identified. Four studies used group-based interventions and two adopted individual intervention. Intervention period ranged from 4 to 20 weeks, and the number and duration of face-to-face contact varied. Core components of the CBT intervention included cognitive restructuring, personal goal setting and promotion of physical activities. The risk of bias was low across the included studies. Our analysis suggests that CBT interventions have significant immediate and retention effects up to 12 months on reducing fear of falling, and 6 months post-intervention effect on enhancing balance., Conclusions: CBT appears to be effective in reducing fear of falling and improving balance among older people. Future researches to investigate the use of CBT on reducing fear of falling and improving balance are warranted., (© The Author(s) 2018. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Objective: To investigate whether two additional home visits improve outcomes for rehabilitation outpatients with balance impairments compared to usual care., Design: Randomized controlled trial., Setting: Outpatient rehabilitation., Participants: Fifty with balance impairments., Interventions: Both groups received usual care including weekly group exercise over eight weeks. The intervention group received two home visits to individualize home exercises., Outcome Measures: Primary outcome measure was the Balance Outcome Measure for Elder Rehabilitation (BOOMER) score, and secondary outcomes included force platform measures using the NeuroCom Balance Master ® , assessed at baseline, after intervention and three-month follow-up., Results: There was no between-group difference for BOOMER score. There were significant between-group differences in favour of the intervention group for limits of stability reaction time at week 9 (mean difference (MD) -0.27, 95% confidence interval (CI) -0.44 to -0.09) and week 22 (MD -0.28, 95% CI -0.45 to -0.10) and for limits of stability maximal excursion at week 9 (MD 8.66, 95% CI 1.67 to 15.65) and week 22 (MD 14.58, 95% CI 7.59 to 21.57). Significant between-group differences favoured the control group for Clinical Test of Sensory Interaction of Balance at week 9 (MD 0.40, 95% CI 0.13 to 0.66) and week 22 (MD 0.45, 95% CI 0.18 to 0.72) and step quick turn time at week 9 (MD 0.56, 95% CI 0.02 to 1.10)., Conclusion: Two exercise-focussed home visits improved some dynamic balance outcomes in older patients with balance impairments. Some outcomes showed significant improvements with small effect sizes in favour of the control group which may be chance findings or because they completed a standard home exercise programme.

Objective: fall-related injuries constitute major health risks in older individuals, and these risks are projected to increase in parallel with increasing human longevity. Impaired postural stability is a potential risk factor related to falls, although the evidence is inconclusive, partly due to the lack of prospective studies. This study aimed to investigate how objective measures of postural sway predict incident falls., Design, Setting and Participants: this prospectively observational study included 1,877 community-dwelling individuals aged 70 years who participated in the Healthy Ageing Initiative between June 2012 and December 2015., Measurements: postural sway was measured during eyes-open (EO) and eyes-closed (EC) trials using the Wii Balance Board. Functional mobility, muscle strength, objective physical activity and cognitive performance were also measured. Participants reported incident falls 6 and 12 months after the examination., Results: during follow-up, 255 (14%) prospective fallers were identified. Division of centre of pressure (COP) sway lengths into quintiles revealed a nonlinear distribution of falls for EO trial data, but not EC trial data. After adjustment for multiple confounders, fall risk was increased by 75% for participants with COP sway lengths ≥400 mm during the EO trial (odds ratio [OR] 1.75, 95% confidence interval [CI] 1.09-2.79), and approximately doubled for sway lengths ≥920 mm during the EC trial (OR 1.90, 95% CI 1.12-3.22)., Conclusion: objective measures of postural sway independently predict incident falls in older community-dwelling men and women. Further studies are needed to evaluate whether postural sway length is of interest for the prediction of incident falls in clinical settings., (© The Author 2017. Published by Oxford University Press on behalf of the British Geriatrics Society.All rights reserved. For permissions, please email: journals.permissions@oup.com)

Background & Aims: Cognitive dysfunction in cirrhotic patients with minimal hepatic encephalopathy (MHE) is associated with falls. Alterations in postural control and stability could contribute to increase falls risk in these patients. We aimed to assess whether postural control and direction-specific limits of stability are altered in cirrhotic patients with MHE compared to patients without MHE and controls. We also assessed if alterations in postural control correlate with neurological impairment and/or blood biomarkers., Methods: Posturography analysis, attention Stroop test and bimanual and visuo-motor coordination tests were performed in 18 controls, 19 patients with cirrhosis without MHE and 17 with MHE, diagnosed by PHES. Posturography was assessed by NedSVE ® /IBV system under four sensory conditions. Limits of stability and rhythmic weight-shifting tests were also performed. Blood ammonia and serum interleukins were also measured. Falls were assessed after 12-24 months follow-up., Results: MHE patients show impaired balance, mainly on unstable surface with eyes open, with longer reaction and confinement times and lower success in Limits of Stability test compared to patients without MHE. Performance in attention and motor coordination tests correlated with most posturography parameters alterations. Logistic regression analysis shows that posturography parameters and bimanual coordination test are good predictors of falls., Conclusion: Balance patterns and limits of stability in MHE patients are impaired compared to patients without MHE and controls. This seems to contribute to a higher falls risk. Attention and motor coordination deficits could contribute to balance impairment in patients with MHE., (© 2016 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Objective: To report the introduction and impact of non-medical prescribing, initiated to improve patient pathways for those presenting with dizziness and balance disorders., Methods: The Southport and Ormskirk physiotherapy-led vestibular clinic sees and treats all patients with dizziness and balance disorders referred to the ENT department. Letters are triaged by an audiologist, who also performs an otological examination and hearing test; this is followed by an assessment with the independent prescriber physiotherapist. An ENT consultant is nearby if joint consultation is needed. Diagnoses, treatments and patient satisfaction were studied, with an analysis of the impact of medication management (stopping or starting medicines) on patients and service., Results: In 12 months, 413 new patients with dizziness and balance disorders had appointments. The most common diagnoses were benign paroxysmal positional vertigo and vestibular migraine. Eighty-four per cent of patients required self-management strategies, 50 per cent exercise therapy, 48 per cent medication management and 24 per cent a particle repositioning manoeuvre. Patient satisfaction was high (99 per cent)., Conclusion: Having an independent prescriber physiotherapist leading the balance clinic has reduced the number of hospital visits and onward referrals. Nearly half of all patients required medication management as part of their dizziness or balance treatment.

Background: The aging of posture and balance function alters the quality of life in older people and causes serious problems in terms of public health and socio-economic costs for our modern societies., Method: This article reviews the various causes of imbalance and dizziness in the elderly, and considers how to prevent falls, and how to rehabilitate a faller subject in order to regain a good quality of life. Two effective ways of intervention are discussed, emphasizing the crucial role of physical activity and cognitive stimulation, classic or using the latest technical advances in virtual reality and video games., Results: Fall in the elderly result from aging mechanisms acting on both the sensorimotor and cognitive spheres. The structural and functional integrity of the peripheral sensory receptors and the musculoskeletal system deteriorate with age. The brain ages and the executive functions, memory, learning, cortical processing of information, sharing of attentional resources and concentration, are modified in the elderly. Psychological affective factors such as depression, anxiety and stress contribute also to speed up the sensorimotor and cognitive decline. The rehabilitation of the postural balance in the elderly must take into account all of these components., Conclusion: The aging of the population and the increased of lifespan are a challenge for our modern societies regarding the major health and socio-economic questions they raise. The fall in the elderly being one of the dramatic consequences of the aging equilibration function, it is therefore imperative to develop rehabilitation procedures of balance., (Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.)

Background: There is growing evidence for the positive effects of exercise training programs on balance control in Parkinson disease (PD). To be effective, balance training needs to be specific, progressive, and highly challenging. Little evidence exists, however, for how people with PD-related balance impairments perceive highly challenging and progressive balance training programs with dual-task components., Objective: The purpose of this study was to explore and describe perceptions of a highly challenging balance training program among people with mild to moderate PD., Design: This study was qualitative in nature. In-depth interviews were conducted with 13 individuals with mild to moderate PD who had participated in a highly challenging balance training program. Interview transcripts were analyzed using qualitative content analysis, with an inductive approach., Results: The analysis revealed 3 subthemes concerning participants' perceptions of highly challenging and progressive balance training: (1) movement to counter the disease, (2) dual-task training in contrast to everyday strategies, and (3) the struggle to maintain positive effects. The first subtheme reflects how physical activity was used as a short-term and long-term strategy for counteracting PD symptoms and their progression. The second subtheme incorporates the described experiences of being maximally challenged in a secure and supportive group environment, circumstances that stood in contrast to participants' everyday lives. The third subtheme describes participants' long-term struggle to maintain program effects on cognitive and physical function in the face of disease progression. Interpretation of the underlying patterns of these subthemes resulted in one overarching theme: training at the limits of balance capacity causes a rethinking motor and cognitive resources., Limitations: The findings of this study cannot be considered to reflect the beliefs of those with weaker or negative beliefs concerning physical activity or be transferred to those at more severe stages of the disease., Conclusions: Findings from this study suggest that being pushed to the limits of balance capacity provoked people with mild to moderate PD to rethink their individual motor and cognitive resources, a process that was further enabled by the PD-specific group setting., (© 2017 American Physical Therapy Association)

Older adults with type 2 diabetes have significantly higher incidence of falls than those without type 2 diabetes. The devastating consequences of falls include declines in mobility, activity avoidance, institutionalization and mortality. One of the most commonly identified risk factors associated with falls is impaired balance. Balance impairments and subsequent increased fall risk in older adults with type 2 diabetes are most commonly associated with diabetic peripheral neuropathy (DPN). Consequently, DPN has been the central focus of falls prevention research and interventions for older adults with type 2 diabetes. However, isolated studies have identified adults with type 2 diabetes without overt complications of DPN to also be at increased fall risk. It is known that the ability to maintain balance is a complex skill that requires the integration of multiple sensorimotor and cognitive processes. Emerging evidence suggests that diabetes-related subtle declines in sensory functions (somatosensory, visual and vestibular), metabolic muscle function and executive functions may also contribute to increased fall risk in older adults with type 2 diabetes. Knowledge of these type 2 diabetes-related sensorimotor and cognitive deficits may help to broaden approaches to falls prevention in older adults with type 2 diabetes. Therefore, the purpose of this mini review is to describe the impact of type 2 diabetes on sensorimotor and cognitive systems that may contribute to increased fall risk in older adults with type 2 diabetes., (Copyright © 2015 Canadian Diabetes Association. Published by Elsevier Inc. All rights reserved.)

Background: Vertigo and dizziness are among the most prevalent symptoms in neurologic disorders. Although many of these patients suffer from postural instability and gait disturbances, there is only limited data on their risk of falling., Methods: We conducted a controlled cross-sectional study at the tertiary care outpatient clinic of the German Center for Vertigo and Balance Disorders using a self-administered questionnaire to assess falls, fall-related injuries, and fear of falling. The recruitment period was 6 months., Results: A total of 569 patients (mean age 59.6 ± 17.1 years, 55% females) and 100 healthy participants were included (response rate > 90%). Dizzy patients with central balance disorders (Parkinsonian, cerebellar, and brainstem oculomotor syndromes) had the highest fall rates (> 50% recurrent fallers, odds ratio > 10). The rate of recurrent fallers was 30% in bilateral vestibular failure and peripheral neuropathy (odds ratio > 5). Patients with functional dizziness (somatoform or phobic vertigo) were concerned about falling but did not fall more often than healthy controls (odds ratio 0.87)., Conclusion: Falls are common in patients presenting to a dizziness unit. Those with central syndromes are at risk of recurrent and injurious falling. Fall rates and fear of falling should be assessed in balance disorders and used to guide the regimen of rehabilitation therapy. The identification of risk factors would help provide protective measures to these groups of patients.

Background: Fibromyalgia (FM) is a rheumatic disease characterized by chronic widespread pain and symptoms such as fatigue, sleep disturbances, cognitive difficulties, and depression. Postural instability is a debilitating disorder increasingly recognized as part of FM., Objective: To assess and compare postural control and balance self-efficacy in women with and without FM and verify the association of these variables with pain, symptom severity, and strength., Design: Case-control study, Setting: Physiotherapeutic Clinical Research and Electromyography Laboratory Department of Physical Therapy, Speech Therapy, and Occupational Therapy, School of Medicine, University of Sao Paulo, Sao Paulo, Brazil., Population: Case-control study of 117 women ranging from age 35 to 60 years. Of these, 67 had FM., Methods: Posture control was assessed with the modified clinical test of sensory interaction on balance with patients in forceplates, balance self-efficacy with the Activities-specific Balance Confidence Scale, pain severity with the Visual Analog Scale, tender point pain threshold with digital algometry, symptom severity with the fibromyalgia impact questionnaire, and lower limb strength with a dynamometer., Results: Individuals with FM had impaired postural control showing increased speed of oscillation of the center of gravity (P=0.004) and decreased balance self-efficacy (P<0.001). They had moderate to excellent correlations of balance self-efficacy with pain (r=0.7, P<0.01), muscle strength (r=0.52, P<0.01), and symptom severity (r=0.78, P<0.10) compared with the control group. Correlation of postural control with the same variables was weak., Conclusions: Patients with FM have impaired postural control and low balance self-efficacy that are associated with pain, muscle strength, and symptom severity., Clinical Rehabilitation Impact: Postural control and balance self-efficacy needs to be assessed in patients with FM and the treatment goals should be the improvement of postural control and balance self-efficacy.

Objective: To evaluate the effects of a 12-week balance training programme on self-assessed function and disability in healthy community-dwelling older adults with self-perceived balance deficits and fear of falling., Design: A prospective, randomized controlled trial., Setting: Stockholm County, Sweden., Participants: A total of 59 community-dwelling older adults (42 women and 17 men) aged 67-93 were randomized to either an intervention group (n = 38) or to serve as controls (n = 21) after baseline testing., Intervention: The intervention was a 12-week, three times per week, progressive, specific and individually adjusted group balance-training programme., Main Measures: Self-perceived function and disability measured with Late Life Function and Disability Instrument., Results: The intervention group reported improvement in overall function (p = 0.016), as well as in basic (p = 0.044) and advanced lower extremity function (p = 0.025) compared with the control group. The study showed no improvement in overall disability or upper extremity function., Conclusion: This group balance training programme improves self-assessed function in community-dwelling older adults with balance deficits and fear of falling., (© The Author(s) 2014.)

Background: The Functional Gait Assessment (FGA) is commonly used to measure walking balance. The minimal clinically important difference (MCID) has yet to be determined for the FGA., Objective: The purposes of this study were to determine: (1) the MCID in the FGA for older community-dwelling adults relative to patients' and physical therapists' estimates of change and (2) the extent of agreement between patients' and physical therapists' estimates of change., Design: This study was a prospective case series., Methods: Patients and physical therapists rated the amount of change in balance while walking after an episode of physical therapy for balance retraining on a 15-point global rating of change (GROC) scale. Weighted kappa statistics were calculated to express agreement between patients' and physical therapists' GROC ratings. Functional Gait Assessment change scores were plotted on receiver operating characteristic curves. A cutoff of +3 on the GROC was the criterion used for important change. The optimal FGA change cutoff score for MCID was determined, and sensitivity (SN), specificity (SP), and likelihood ratios (LRs) were calculated., Results: One hundred thirty-five community-dwelling older adults (average age=78.8 years) and 14 physical therapists participated. There was poor agreement between the patients' and therapists' ratings of change (weighted kappa=.163). The estimated MCID value for the FGA using physical therapists' ratings of change as an anchor was 4 points (SN=0.66, SP=0.84, LR+=4.07, LR-=0.40). No accurate value for the FGA MCID could be determined based on the patients' ratings of change., Limitations: The small sample size was a limitation., Conclusion: Poor agreement between therapists' and patients' ratings indicate the need for further communication relative to patient goals. The 4-point MCID value for the FGA can be used for goal setting, tracking patient progress, and program evaluation., (© 2014 American Physical Therapy Association.)

Purpose: To evaluate the effectiveness of the Nintendo Wii compared to traditional balance therapy in improving balance, motivation, and functional ability in children undergoing acute rehabilitation after brain injury., Methods: A non-concurrent, randomized multiple baseline single-subject research design was used with three participants. Data were analyzed by visual inspection of trend lines., Results: Daily Wii balance training was equally motivating to traditional balance therapy for two participants and more motivating for one participant. While improvements in dynamic balance were observed, the results for static balance remain inconclusive. All participants demonstrated improvements in functional ability., Conclusion: Wii balance therapy is a safe, feasible, and motivating intervention for children undergoing acute rehabilitation after an acquired brain injury. Further research to examine the effectiveness of Wii balance therapy in this population is warranted.

Background: Acromegaly may lead to balance disturbances and fear of falling due to changes in body composition and co-morbidities., Aim: The aim of this study was to evaluate balance and fear of falling in acromegalic patients and their relation with disease characteristics., Materials and Methods: Forty-eight acromegalic patients and 41 age- and gender-matched controls were enrolled in the study. The median ages of the patients and controls were 48 (25-75) and 50 (25-67) yr, respectively. Berg Balance Scale (BBS) and one-leg stance test (OLST) were used to compare dynamic and static balance respectively, 50 meters walking test was used to compare functional capacity and falls efficacy scale-international (FES-I) was used to compare fear of falling between the groups., Results: Balance tests (BBS and 50 meter walking test) and fear of falling (FES-I) were significantly disturbed in patients compared with controls. There was no significant difference in OLST. BBS and OLST were negatively and FES-I was positively correlated with age. FES-I was negatively correlated with BBS and OLST was positively correlated with 50 meters walking test. Only OLST was negatively correlated with disease duration. Logistic regression analysis revealed that balance was not affected by the presence of co-morbidities, postoperative vision loss and disease control., Conclusions: This is the first study showing that balance is disturbed in acromegalic patients. This disturbance is not related to disease control and co-morbidities but somewhat to disease duration.

Therapeutic management of gait and balance impairment during aging and neurodegeneration has long been a neglected topic. This has changed considerably during recent years, for several reasons: (1) an increasing recognition that gait and balance deficits are among the most relevant determinants of an impaired quality of life and increased mortality for affected individuals; (2) the arrival of new technology, which has allowed for new insights into the anatomy and functional (dis)integrity of gait and balance circuits; and (3) based in part on these improved insights, the development of new, more specific treatment strategies in the field of pharmacotherapy, deep brain surgery, and physiotherapy. The initial experience with these emerging treatments is encouraging, although much work remains to be done. The objective of this narrative review is to discuss several promising developments in the field of gait and balance treatment. We also address several pitfalls that can potentially hinder a fast and efficient continuation of this vital progress. Important issues that should be considered in future research include a clear differentiation between gait and balance as two distinctive targets for treatment and recognition of compensatory mechanisms as a separate target for therapeutic intervention., (© 2013 Movement Disorder Society.)

This study investigated modifications to standing posture in response to elevated postural anxiety evoked by a potential physical threat to stability. Sixteen young adults, 16 older adults and 16 patients diagnosed with Parkinson's disease (PD) stood with or without the expectation of a threat to their posture (i.e., external trunk perturbation). This method allowed for the assessment of the effects of anticipatory anxiety on standing posture associated with an ecologically valid and direct threat to stability. Our manipulation was successful as all participants, independent of age and disease, reported significant increases in postural anxiety when anticipating a threat to their posture. The trunk sway modifications observed in response to elevated postural anxiety were dependent on age and disease. Young adults showed increased trunk sway in both pitch and roll directions while older adults demonstrated decreased trunk sway but only in the roll direction when standing and expecting a threat to posture compared to standing without this threat. Individuals with PD showed no significant changes in trunk pitch or roll sway when anticipating a threat to posture compared to standing without this threat. Our findings suggest that the effects of postural anxiety on postural control are dependent on the context associated with the postural threat, and age and disease status., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objective: To investigate balance, gait, falls, and fear of falling in patients with the hypermobility type of Ehlers-Danlos syndrome (EDS-HT)., Methods: Twenty-two women with EDS-HT and 22 sex- and age-matched healthy control subjects participated in the study. Each subject performed the modified Clinical Test of Sensory Interaction on Balance (mCTSIB) and the Tandem Stance test (TS) on an AccuGait force platform to assess balance by center of pressure-based postural sway measures. The GAITRite walkway system was used to record spatial-temporal gait variables during 3 walking conditions (single task, cognitive task, and functional task). Data about fall frequency and circumstances were collected by retrospective recall, and fear of falling was assessed by the modified Falls Efficacy Scale., Results: Compared with healthy subjects, EDS-HT subjects showed significantly impaired balance, reflected by increased sway velocity, mediolateral and anteroposterior sway excursion, and sway area during mCTSIB and TS. Gait velocity, step length, and stride length were significantly smaller during all walking conditions, and a significant dual-task-related decrement was found for gait velocity, step and stride length, and cadence in the EDS-HT subjects compared to the control group. Ninety-five percent of the patients fell during the past year, and some fear of falling was measured., Conclusion: To our knowledge, this study is the first to establish that EDS-HT is associated with balance and gait impairments, increased fall frequency, and poorer balance confidence, implying a decrease in the safety of standing in everyday life situations. Whether these deficits can be improved by appropriate exercise programs needs to be addressed in future research., (Copyright © 2011 by the American College of Rheumatology.)

Pusher behaviour (PB) reflects some misrepresentation of verticality. However, its neural mechanisms are still unclear. The aim of this pilot study is to assess the perception of the subjective visual vertical in patients with PB using an orientation discrimination task relying on a psychophysical forced-choice procedure. A sample of eight patients with post-stroke hemiplegia, three of whom with (PB+ group) and five without (PB- group) a clear PB, and 10 matched healthy subjects, was selected. All participants were assessed with an orientation discrimination task based on the objective Two-Alternatives Forced Choice (2AFC) procedure, in which observers are forced to report whether an oriented stimulus that was tilted off-vertical by a varying amount (but never vertical) was tilted clockwise or counterclockwise from vertical. Participants' ability in detecting the visual vertical was estimated by calculation of bias and threshold, which represent deviations of the subjective vertical from the physical vertical and the sensitivity to orientation offsets away from vertical, respectively. While there were no significant differences between groups in terms of bias, statistical analysis showed a significantly higher threshold in the PB+ group compared to both PB- and control groups. Results suggest that vertical misrepresentation might be due to the presence, in patients with PB, of a lower signal-to-noise ratio in coding systems. Implications for clinical practice are discussed.

In this article we explore the concept of balance in the context of health. We became interested in balance during a grounded theory study of lay conceptualizations of cancer risk in which participants were concerned with having a good life, which relied heavily on balancing processes. This led us to the qualitative literature about balance in the context of health, which was large and in need of synthesis. We identified 170 relevant studies and used Thomas and Harden's technique of thematic synthesis to identify key balance-related themes and develop these into more abstract analytic categories. We found that balance and balancing were salient to people in three health-related contexts: health maintenance, disease or disability management, and lay or professional caregiving. In each of these contexts, balance or imbalance could be a state or a process. In addition, those using the word balance had either an internally or externally focused orientation to the world around them. Clinicians and public health practitioners might benefit from using these insights in their research and communication.

Objective: This article aimed to critically examine preexisting conceptualizations of the relationship among fear of falling, falls efficacy, and falls and to offer a new theoretical model incorporating findings from the recent literature., Method: This is a theoretical article based on a review of preexisting findings pertaining to fear of falling and falls efficacy., Results: Traditional conceptualizations consider avoidance of activity and deconditioning to be mediators in the relationship between fear of falling and falls, but recent findings suggest that this mediational conceptualization may not be accurate. Moreover, the terms falls efficacy and fear of falling are often used interchangeably in the literature, which is conceptually problematic., Discussion: We conclude with the presentation and discussion of an alternative predictive model of fear of falling that incorporates important findings from the recent literature.

Virtual augmented exercise, an emerging technology that can help to promote physical activity and combine the strengths of indoor and outdoor exercise, has recently been proposed as having the potential to increase exercise behavior in older adults. By creating a strong presence in a virtual, interactive environment, distraction can be taken to greater levels while maintaining the benefits of indoor exercises which may result in a shift from negative to positive thoughts about exercise. Recent findings on young participants show that virtual reality training enhances mood, thus, increasing enjoyment and energy. For older adults virtual, interactive environments can influence postural control and fall events by stimulating the sensory cues that are responsible in maintaining balance and orientation. However, the potential of virtual reality training has yet to be explored for older adults. This manuscript describes the potential of dance pad training protocols in the elderly and reports on the theoretical rationale of combining physical game-like exercises with sensory and cognitive challenges in a virtual environment.

Comorbidity between balance and anxiety disorders in adult population is a well-studied clinical entity. Children might be particularly prone to develop balance-anxiety comorbidity, but surprisingly they are practically neglected in this field of research. The consequence is that children are treated for what seems to be the primary disorder without noticing possible effects on the other disorder. In Study 1, children with balance dysfunction were compared to normally balanced controls on anxiety and self-esteem. In study 2, children with balance dysfunction were assigned to either balance training or a waiting-list control. Training consisted of 12 weekly sessions of balance treatment. Anxiety and self-esteem were tested before and after treatment/waiting. Study 1 confirmed significantly higher anxiety and lower self-esteem in the balance dysfunction group compared to the control group. Study 2 showed that treatment improved balance performance, reduced anxiety, and increased self-esteem relative to the control waiting list group. Taken together, the present findings are in accord with the observations of comorbidity between balance and anxiety disorders in adults and confirm their validity in children younger than 7 years of age. This profile of comorbidity between balance dysfunction and anxiety also include lower self-esteem.

Comorbidity between balance and anxiety disorders has been documented in clinical psychiatric and neurological samples. The authors aimed to determine whether the comorbidity of balance and anxiety disorders has an analogous representation in the normal population. Participants were 20 undergraduate students ages 22-29 years. The authors assigned them to high or low trait anxiety groups and performed a balance task in 3 experimental stages: baseline, training, and test. The baseline and test stages consisted of 4 wobbly and 4 stable trials each. The authors measured state anxiety in the form of auditory startle responses (ASRs) during the stable trials. In the baseline stage, the ASR amplitudes were higher in the high trait anxiety participants. In the test stage, the low trait anxiety participants performed the balance task better than the high trait anxiety participants did. These data suggest that the clinical entity designated as a comorbidity of balance and anxiety disorders has an analogous representation in the normal population.

Purpose: The present study evaluates gross motor abilities and self perception about the physical abilities of pre-school children with amblyopia, in comparison to their unaffected peers., Method: Twenty-two children with amblyopia, and 25 children with normal vision, aged 4-7, were included in this study. Gross motor abilities were evaluated by the Movement Assessment Battery for Children (MABC). The Pictorial Scale of Perceived Competence and Social Acceptance for Young Children were used to measure physical self perception. Parents completed a questionnaire about everyday situations revolving around the child's balance and posture abilities., Results: Amblyopic children performed significantly worse than the controls according to the MABC subtests and the parents' questionnaire total score. In the scale of perceived competence evaluation the amblyopic children had lower scores in half of the items as well as in the total mean score, but the differences between the groups were not significant. Among the study group, significant correlations were found between several items in the parents' questionnaire and the children's' mean balance score in MABC., Conclusions: Amblyopia may negatively impact children's motor abilities as expressed by the objective measures in daily living, while self perception is less affected.

Background and Purpose: Traditionally, rehabilitation programs emphasize training balance under single-task conditions to improve balance and reduce risk for falls. The purpose of this case report is to describe 3 balance training approaches in older adults with impaired balance., Case Descriptions: Three patients were randomly assigned to 1 of 3 interventions: (1) single-task balance training, (2) dual-task training under a fixed-priority instructional set, and (3) dual-task training under a variable-priority instructional set., Outcomes: The patients who received balance training under dual-task conditions showed dual-task training benefits; these training benefits were maintained for 3 months. The patient who received variable-priority training showed improvement on novel dual tasks., Discussion: Older adults may be able to improve their balance under dual-task conditions only following specific types of balance training. This case report gives insight on how this intervention might be combined with more traditional physical therapy intervention.

It is a well-known fact, and there are several publications on this matter, the links between panic attacks, simulation, anxiety, depression and lightheadedness or imbalance, but in our perusal of the related literature no connection between pathological mourning, dizziness and imbalance was found. In this paper are reported the outcomes of a prospective study of 58 patients suffering vertigo and imbalance as well and psychiatrically assessed. Pathologic mourning shows its predominance among otic vertiginous. This feature, we think, should be investigated when collecting the anamnesis of patients complaining of dizziness and/or imbalance in order to planning the appropriate treatment.

Vertigo, dizziness and imbalance are frequent symptoms among patients in clinical practice. We present the development of a new multipurpose measure specific to patients with these symptoms: the VDI questionnaire. Items of the VDI questionnaire were generated through an international panel of clinicians, in-depth interviews with 25 patients and an extensive literature search. Items were reduced by qualitative and quantitative methods. Psychometric properties were tested in 130 patients recruited in primary care general practices, neurologists and ENT out-patient clinics. Patients were clinically evaluated and administered several specific and generic health status instruments: the Balance Scale, the SF-12 Health Survey and the General Health Questionnaire 12 items. The VDI symptoms and the VDI health related quality of life (HRQoL) scales were administered during the visit and some weeks after. Correlation and confirmatory factor analysis were used. Reliability of the VDI was high (0.92 for VDI HRQoL scale and 0.86 for VDI symptoms). VDI scores were more correlated with Balance Scale scores than with mental health indicators. All factor loadings were significantly different from zero and confirmed the expected relations. In the second administration, VDI scores showed a deterioration among those reporting a worsening in their symptoms and an improvement among those reporting feeling better. The data presented suggest that the VDI questionnaire is a reliable, valid and responsive instrument for patients with vertigo, dizziness or imbalance. The VDI questionnaire could be a useful complement of the clinical evaluation of these patients at both group and individual level.

A group of patients with balance complaints (n = 16) was compared with a group of normal subjects (n = 17) by means of posturography, subjective assessments of balance, anxiety and unsteadiness when standing on a force platform with eyes closed. Postural instability was induced by vibratory stimulation of the calf muscles (20, 40, 60, 80 and 100 Hz). As a control condition, the arm (biceps) was stimulated at similar frequencies. In order to control for arousal, blood pressure and heart beat were assessed. Furthermore, questionnaire responses on psychological measures were collected. Results showed clear differences between the groups in terms of imbalance and self-reports. However, the 2 groups displayed similar increases of imbalance during calf stimulation and no increase during arm stimulation. Patients generally rated less increase of unsteadiness when the calf was stimulated than did the controls. No differences in arousal were found between the groups or within conditions. Results are discussed in terms of the proposed desynchrony between symptoms and complaints.

We carried out a questionnaire survey regarding symptoms of orthostatic dysregulation and administered the Japanese Edition of the Cornell Medical Index-Health Questionnaire (JCMI) and the Yatabe-Guilford Personality Test (Y-G test) to 151 male medical students (mean age, 24.6 yr). Orthostatic dysregulation was identified in 19 (12.5%) of the subjects based on the questionnaire results. The percentage classed as types III (possible neurotic) and IV (probable neurotic) according to the health questionnaire was 47.3% in the 19 with orthostatic dysregulation and 8.9% in the controls (n = 78). The percentage classed as types B and E, suggestive of emotional or psychological disturbance according to the personality test, was 42.1% in those with orthostatic dysregulation and 8.9% in the controls. These differences were significant (P < 0.01). These results suggest that psychosomatic factors influence the occurrence of orthostatic dysregulation in young men.